MEDICARE: LAKE SHORE FIRE DEPARTMENT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	341600000X	Ambulance	04166	PA

General Provider Information

NPI Number	:	1609081033
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE SHORE FIRE DEPARTMENT

Provider Business Mailing Address
First Line	:	5310 W LAKE RD
Second Line	:	PO BOX 8566
City	:	ERIE
State	:	PA
Zip	:	16505-2869
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5310 W LAKE RD
Second Line	:
City	:	ERIE
State	:	PA
Zip	:	16505-2869
Country	:	US
Telephone Number	:	814-833-6508
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	SARA O'BRIEN
Credential	:
Telephone Number	:	814-833-6508

Provider Enumeration Date	:	05/11/2007
Last Update Date	:	11/12/2008

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Directions to “LAKE SHORE FIRE DEPARTMENT ” Practice Location

Language	Start Address	Practice Location

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